Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Poplar Care Strategies during CMS and state inspections, most recent first.
A resident with diagnoses including heart failure and anxiety was admitted without a baseline care plan developed within 48 hours to address immediate and individualized care needs. An Interim Care Plan assessment for this resident was started but not completed, so no individualized interim care plan was in place. The DON reported that the admitting nurse typically completes this assessment to initiate the interim care plan, but this did not occur, despite facility policy requiring a baseline plan of care to be developed within 48 hours of admission.
The facility failed to prevent accident hazards when a resident on continuous O₂ was placed in a shared room with another resident who had a documented history of non‑compliance with the no‑smoking policy, including repeated marijuana and vape use. Despite prior notes of marijuana or vape odors in the room and hallway, a report of smoking in the lobby, and staff suspicion and later confirmation that the resident possessed a vape device, the two residents remained roommates. The O₂‑dependent resident and his spouse reported that the roommate smoked in the shared bathroom, with smoke observed while the O₂ concentrator was running, and staff acknowledged that smoking by this resident had been an ongoing problem.
A resident with heart failure and anxiety was observed receiving continuous supplemental O2 via nasal cannula from a concentrator, with the flow set just above 2 L, and reported using O2 at all times. Record review showed the resident had been receiving O2 every shift since admission, but there was no physician order for routine O2 therapy, no clarification of the required O2 flow rate, and no care plan addressing ongoing O2 use. An LPN confirmed the resident routinely received supplemental O2 and should have had a physician order, contrary to facility policy requiring verification of an order before O2 administration.
Failure to maintain resident privacy and confidentiality occurred when multiple staff members entered a resident's room without knocking, including an LPN, CNAs, an RN, and a Maintenance Assistant. An LPN also entered another resident's room without knocking, and an RN entered a third resident's room without knocking. In addition, two RNs performed a dressing change for a resident with the door and curtain open while others passed by the room. A CNA stated staff should knock before entering and close curtains and blinds during care.
The facility failed to ensure the activities program was directed by a qualified professional. The Activities Director had resigned, the Activities Assistant was overseeing activities but was not certified, and the facility lacked a current Activities Director in employee records. The Administrator stated the prior Activities Director’s last day was 12/12/25 and that no consultant had been used after the resignation.
Staff failed to follow infection control practices during resident care, including not wearing gowns for EBP, not sanitizing hands between glove changes, and not performing adequate hand hygiene after glove removal. A CNA scraped a clean brief on the floor before placing it on a resident, an RN placed an open heel wound on bed linen during a dressing change, and another staff member brushed a clean pull-up against soiled socks during toileting care.
Unsafe and Unsanitary Room Conditions: Multiple resident rooms had strong urine odors, dirty or brown-stained toilet areas, dust-caked exhaust fans, brown call light strings, unlabeled toiletries, and other unsanitary conditions. One room had green faucet handles and base, another had a towel on the floor near the A/C unit and a chipped toilet seat riser, and two bathrooms had only 1 of 2 lights working. The Mnt Supervisor said he was unaware of several issues and relied on staff reports for non-life-safety concerns.
Failure to assess self-administration of medication. A cognitively intact resident with asthma was observed with fluticasone propionate nasal spray at the bedside and stated he used it whenever needed. The record lacked a current order for the medication, a care plan for self-administration, and a self-administration assessment, and an RN confirmed the resident used the spray in his room without a current bedside order.
A resident with severe cognitive impairment, incontinence, and MASD did not receive ordered toileting and hygiene assistance every 2 hours. The resident required substantial to maximum staff help with toileting and had repeated redness, excoriation, and skin breakdown to the buttocks, groin, labia, and perineum. The record lacked documentation that the toileting order was followed, and observation showed the resident in saturated clothing and incontinence products while staff passed by without addressing the need for care.
A resident with dementia, polyneuropathy, and a right ankle pressure injury developed a worsening Stage III ulcer with slough, drainage, pain, and recurrent infection. The record lacked consistent weekly skin assessments, wound measurements, and wound characteristic documentation, and the care plan was not shown to be re-evaluated when the resident refused offloading and wound care. MAR/TAR entries showed treatments were marked complete, but surveyors observed missing ordered nutrition support, including double protein, Magic Cup, and visible protein powder, and staff interviews showed confusion about the wound and nutrition orders.
Failure to Supervise a Resident With Recurrent Falls: A resident with dementia, impaired gait and mobility, unsteadiness on feet, and a history of recurrent falls was supposed to be supervised at all times in the lounge and not left alone in her wheelchair. She was found on the floor after a pressure alarm sounded, and the record lacked both a fall assessment and an IDT note after the fall.
A resident with dementia, a pressure ulcer, and weight loss did not consistently receive the ordered nutrition plan. Staff failed to provide the ordered double protein portions, Magic Cup supplements, and protein powder as directed, and the resident was not being weighed weekly as ordered after significant weight loss was identified. The nutrition care plan was also not revised to reflect the resident's changing needs.
A resident reported hearing CNAs speak harshly to residents, use foul language, and force residents to get up or go to bed against their wishes, which upset her. Resident council minutes and grievances showed repeated complaints that staff were mean, abrasive, snippy, and unprofessional, including cursing and poor tone. The DON and Administrator acknowledged the complaints and said staff had been counseled and in-serviced on resident rights, professionalism, and respectful communication.
Surveyors identified that medications brought in by a resident's family were stored in a medication cart without proper labeling or a physician's order, and there was no documentation in the medical record or notification to the physician. Additionally, a medication storage refrigerator containing both resident beverages and medications had incomplete temperature log documentation, contrary to facility policy. Staff interviews confirmed that required procedures for medication labeling, physician orders, and temperature monitoring were not followed.
Staff failed to perform hand hygiene after removing gloves and before donning new gloves while assisting a resident with toileting and personal care. After glove removal, a CNA also handled the resident's personal items without hand hygiene, contrary to facility policy and infection prevention standards.
The facility failed to prevent and treat pressure wounds for two residents, leading to deficiencies in care. One resident, with multiple wounds and at risk for pressure injuries, did not have a care plan in place, and treatments were missed due to the resident being asleep. Another resident's coccyx wound worsened from a pink area to a Stage II pressure wound, with inadequate documentation and communication regarding the wound's progression. Staff interviews revealed a lack of awareness and communication about the residents' conditions, contributing to the deficiencies.
The facility did not ensure a qualified Infection Preventionist was working at least part-time. The DON, who was also the appointed IP, indicated that the time spent on IP duties varied and was insufficient. There was no documentation of hours worked for IP duties, and the job description for the IP role was undated.
A facility failed to document a clinical contraindication for not performing a gradual dose reduction (GDR) on a resident's psychotropic medication. The resident, with anxiety and depression, was on Alprazolam 0.5mg twice daily. A GDR was recommended but denied without documented contraindication, contrary to the facility's policy requiring GDR attempts unless clinically contraindicated.
The facility failed to maintain professional standards in food safety and hygiene. Observations revealed dietary staff with hair not fully covered by hairnets, incomplete food temperature logs, and improper storage of measuring devices in food containers. Staff were seen handling food with bare hands, and resident trays were transported with uncovered food items. These actions were contrary to the facility's policy requiring covered food, proper hair containment, and glove use.
The facility failed to ensure proper hand hygiene during incontinence care for three residents. CNAs did not perform hand hygiene between glove changes and did not change gloves after touching multiple items before starting care. The Infection Preventionist noted that staff should sanitize hands before putting on gloves and between dirty and clean tasks, as per the facility's Handwashing/Hand Hygiene Policy.
The facility failed to ensure a sanitary and homelike environment, with issues such as unlabeled personal items, dust-caked vent fans, soiled toilets, and peeling non-skid strips observed across multiple areas. Interviews with staff revealed a lack of adherence to cleaning protocols and labeling of personal items, despite expectations outlined in the facility's policy.
The facility failed to update care plans for three residents, leading to deficiencies. A resident continued using bed and chair alarms without a current physician's order, while another had alarms in use without documentation in the care plan. Additionally, a third resident's care plan included outdated interventions for diuretic and antibiotic therapy. Staff interviews and observations confirmed these oversights, indicating non-compliance with facility policies on care plans and alarms.
The facility failed to provide adequate respiratory care for three residents, including not following physician orders for oxygen levels, improper storage of respiratory equipment, and lack of a physician's order for oxygen use. Residents with COPD and other conditions were affected, and staff interviews confirmed discrepancies in care and adherence to infection control protocols.
The facility failed to meet pharmaceutical service needs, as a nurse administered medications from other residents' supplies due to missing prescriptions. The DON cited issues with the pharmacy, including delayed deliveries and lack of after-hours support, leading to medication borrowing against policy.
A resident with dementia exited a facility unsupervised due to a failure in the alarm system on a back door, which had been silenced and not reset. The resident, who had a history of elopement and was wearing a WanderGuard bracelet, was found 200 yards off the property. The back door lacked a WanderGuard system, and the resident's care plan interventions were insufficient to prevent the incident.
A resident's privacy was violated when a video was recorded in their restroom, showing them on the commode. The video, posted on social media by an unlicensed staff member, led to the suspension and termination of two staff members. The resident, with moderate cognitive impairment, was exposed in the video, violating facility policies on privacy and HIPAA regulations.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one of three newly admitted residents reviewed. Record review on 4/28/26 showed that Resident B, whose diagnoses included heart failure and anxiety, was admitted on an unspecified date and did not have a baseline care plan in place addressing individualized care needs. An Interim Care Plan assessment for this resident, dated 4/21/26, had been initiated but was not completed, and therefore no individualized interim care plan was in place. During an interview on 4/29/26, the DON stated that the admitting nurse usually completed the Interim Care Plan assessment, which would then initiate an individualized interim care plan. The facility’s policy, dated 2026, required that a baseline plan of care to meet each resident’s immediate health and safety needs be developed within 48 hours of admission. This deficiency was cited in relation to Intakes 29994502, 2738801, and 2989481. This deficiency was cited under 410 IAC 16.2-3.1-30(a).
Failure to Prevent Smoking-Related Accident Hazards in Shared Room with Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to prevent accident hazards by placing a resident on continuous supplemental O₂ in a shared room with another resident who had a documented history of non‑compliance with the facility’s no‑smoking policy. One resident, diagnosed with heart failure and anxiety and routinely receiving 2 L of O₂ via nasal cannula from an in‑room concentrator, reported that his roommate smoked in their shared bathroom, causing him difficulty breathing. Staff notes documented that the resident’s spouse called to report the roommate was smoking in the bathroom, and the resident later described seeing his roommate wheel out of the bathroom with a cloud of smoke behind him while he was on O₂. A no‑smoking sign was posted outside the room due to oxygen in use. The roommate had multiple prior documented incidents related to marijuana and vape use despite having signed the facility’s smoke‑free/tobacco‑free policy on admission. His diagnoses included cannabis use, hallucinations, and delusional disorder, and his care plan noted that he had brought marijuana and marijuana vape pens into the facility. Nursing notes described repeated reports of marijuana or vape odors in his room and hallway, and an incident where a visitor reported he was smoking marijuana in the lobby, with staff suspecting he possessed a marijuana vape pen. Staff interviews confirmed that smoking in the facility by this resident had been an ongoing problem, that a vape device had been found in his room and confiscated by police, and that on the night of the reported bathroom smoking incident, it was obvious he had been smoking even though he initially denied it. The facility’s accident/incident policy referenced review of reports for trends and resident vulnerabilities, but the residents continued to be roomed together despite the known smoking behavior and the roommate’s O₂ use.
Lack of Physician Order and Care Plan for Routine Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving routine supplemental oxygen had corresponding physician orders and a plan of care for that oxygen therapy. During observation, one resident was seen wearing supplemental oxygen via nasal cannula connected to an oxygen concentrator in a shared room. Record review showed this resident had diagnoses including heart failure and anxiety and had been receiving oxygen via nasal cannula daily, every shift, from admission through the review period. However, the physician orders did not include any order for routine supplemental oxygen or clarification of the oxygen flow rate, despite an existing order to monitor temperature and oxygen levels every shift. Further observation showed the resident wearing a nasal cannula and receiving oxygen from a concentrator set just above 2 L, and the resident reported receiving oxygen at all times. Interview with an LPN confirmed that the resident did receive routine supplemental oxygen and should have had a physician’s order for this ongoing use. Record review also confirmed there was no plan of care addressing the resident’s routine supplemental oxygen. The facility’s own policy on oxygen administration required verification of a physician’s order prior to the procedure, but this was not followed for this resident’s continuous oxygen therapy.
Failure to Maintain Resident Privacy During Room Entry and Care
Penalty
Summary
The facility failed to ensure resident privacy and confidentiality for 4 of 4 random observations. Multiple staff members entered Resident 21's room without knocking, including an LPN and CNA on 1/6/26 at 3:19 A.M., a CNA on 1/5/26 at 10:09 A.M., an RN on 1/7/26 at 9:23 A.M., and a Maintenance Assistant on 1/7/26 at 9:35 A.M., while Resident 21 was in the room each time. An LPN also entered Resident 10's room without knocking on 1/6/26 at 3:18 A.M., and an RN entered Resident 9's room without knocking on 1/7/26 at 9:45 A.M. while that resident was present. Resident 3 was also involved in privacy concerns. On 1/5/26 at 10:09 A.M., two CNAs entered Resident 3's room without knocking to assist her out of bed. On 1/6/26 at 9:35 A.M., two RNs performed a dressing change for Resident 3 with the door and curtain left open, and two staff members were observed walking past the room, with one stopping to speak with one of the RNs. On 1/7/26 at 9:52 A.M., a CNA stated that staff should provide privacy by knocking before entering rooms and by pulling curtains and shutting blinds before providing care. The Administrator later provided the facility's Resident Care and Dignity policy, revised 1/2024, which stated that federal and state laws guarantee residents the right to privacy and confidentiality.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
Ensure the activities program is directed by a qualified professional. Based on interview and record review, the facility failed to ensure the Activity Director was certified for 1 of 1 Activity Director reviewed. During interviews, the Administrator stated the Activities Director had recently resigned and the Activities Assistant was currently overseeing activities. The Activities Assistant stated she was not certified and that the facility currently lacked an Activities Director. The Administrator later stated the previous Activities Director’s last day worked was 12/12/25 and that the facility had not utilized a consultant after she resigned. Record review on 1/8/26 showed employee records lacked a current Activity Director. The Administrator also provided a current, undated Nursing Home Activities: Resident Rights and the Role of Activities Staff policy stating the activities program must be directed by a qualified professional who meets specified qualifications.
Infection Control Failures During Incontinence and Wound Care
Penalty
Summary
The facility failed to ensure an infection control program was followed during incontinence care and wound care for multiple residents. During observation, CNA 25 assisted a resident with toileting without wearing a gown despite Enhanced Barrier Precautions signage and PPE being available outside the room. The CNA removed a soiled brief, then scraped a clean brief on the floor before placing it on the resident. In another observation, RN 21 and RN 5 changed a heel dressing on a resident with diagnoses including viral hepatitis and dementia, and the resident’s open heel wound was placed on the bedding during the procedure before being repositioned on a drape. Additional observations showed staff failing to perform hand hygiene and use PPE correctly during care for residents with incontinence, colostomy care, and wound-related precautions. CNA 25, CNA 9, and LPN 15 assisted a resident with incontinence and colostomy care without wearing gowns, and handwashing times observed were 12 seconds, 6 seconds, and 14 seconds. During another incontinence care episode, CNA 25 changed gloves without sanitizing hands between glove changes. LPN 17 and CNA 18 removed soiled briefs and did not perform hand hygiene after removing gloves before continuing care. QMA 32 also brushed a clean pull-up against a resident’s soiled socks while applying it. The residents involved included one with a sacral pressure ulcer and colostomy, one dependent on staff for toileting, and another with wounds requiring Enhanced Barrier Precautions.
Unsafe and Unsanitary Room Conditions
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and homelike environment for residents, staff, and visitors in 6 of 10 rooms observed. Room A1, shared by 3 residents, was observed with a strong urine odor, brown substance smeared on the raised toilet seat with handles and down the front of the toilet, 2 unlabeled bottles of moisturizing shampoo and body wash, an open tube of over-the-counter lotion and another unlabeled rash ointment on the back of the toilet, dust caked on the exhaust fan, a brown call light string, blue splatters on the wall to the left of the toilet and down the front of the toilet, and brown tiles around the base of the toilet. On a later observation, Room A1 still had a strong urine odor, dust caked on the exhaust fan, a brown call light string, and brown tiles around the base of the toilet. Room A4, a private room, was observed with a strong urine odor, dust caked on the exhaust fan, a brown call light string, and brown tiles around the base of the toilet on two observations. Room F2 had green faucet handles and base on two observations. Room B2 had a rolled-up towel on the floor in front of the air conditioning unit and a toilet seat riser with chipped paint on the legs where the resident's legs would sit; the towel was later noted to have a yellowed stain, and the Maintenance Supervisor stated he was unaware of the issue and would need to replace the riser. Room B6 and Room B3 each had only 1 of 2 bathroom lights working on repeated observations, and the Maintenance Supervisor stated he was unaware the lights were out. He also stated he scheduled monthly maintenance checks mainly for life safety issues and depended on staff to report other issues; a preventative maintenance policy was requested but not provided.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident who was self-administering medication was assessed for the ability to do so. Resident 32, who had a diagnosis of asthma and was cognitively intact per the most recent MDS assessment, was observed sitting in a wheelchair with oxygen via nasal cannula and had fluticasone propionate nasal spray on the bedside table. The resident stated he used the nasal spray whenever he needed to. Review of the clinical record showed no current order for fluticasone propionate, no care plan related to self-administering medications, and no self-administration assessment. RN 3 stated the resident used the nasal spray in his room and that the record lacked a current order to keep the nasal spray at bedside. The facility’s medication administration policy stated residents may self-administer medications only with a prescriber’s order and when the interdisciplinary team has determined the practice would be safe.
Failure to Provide Ordered Toileting and Hygiene Assistance
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for ADLs received the toileting and personal hygiene assistance ordered by the physician. The resident had diagnoses including osteoarthritis and dementia without behaviors, was severely cognitively impaired, and required substantial to maximum assistance with toileting and transfers. The quarterly MDS also indicated the resident was always incontinent of bowel and bladder and had MASD skin conditions. The resident’s physician ordered staff to offer toileting every two hours and as needed, day and night, and to cleanse the perineal area and apply barrier cream to red and open areas. The skin impairment care plan identified weakness, impaired mobility, yeast to the groin area, incontinence, and chronic excoriation to the buttocks. Progress notes documented MASD to the intergluteal cleft, coccyx, buttocks, labia, and perineum, with redness, excoriation, itching, burning, and scratched-open areas noted over time. The clinical record lacked documentation that the resident was encouraged and toileted every two hours as ordered. During observation, staff assisted the resident to the toilet and removed a saturated incontinence pad and saturated pants, and the resident was noted to have redness to the buttocks. During a later continuous observation, the resident remained in the dining room and hallway for an extended period, and two CNAs passed by without addressing the resident before the Activities Assistant later asked if the resident wanted to go to an activity and pushed the resident in a wheelchair to the activity area. An LPN stated the resident needed staff assistance for toileting and thorough hygiene care and should be encouraged to toilet every two hours, while the DON stated she expected the order to be followed and documented.
Failure to Monitor and Treat a Worsening Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent a facility-acquired pressure ulcer from worsening for one resident with dementia with behaviors, polyneuropathy, and a right ankle pressure injury. The resident’s record showed the wound progressed from a small red, warm, intact area on the outer right ankle to a Stage III pressure ulcer with exposed fat layer, slough, drainage, and recurrent infection. The resident also had pain associated with the wound, and the record reflected repeated refusals of offloading measures and intermittent resistance to wound care. The clinical record lacked quarterly skin assessments between documented Braden Scale assessments, and the resident’s wound was not consistently measured or described in weekly documentation. Although the care plan included weekly wound monitoring, reporting changes, following facility skin breakdown protocols, and revising interventions when the resident refused treatment, the record lacked documentation that the plan was discussed, re-evaluated, or revised based on the resident’s ongoing wound status and refusals. The MAR/TAR showed treatments and medications were marked as given, but there was no accompanying wound documentation showing wound characteristics, measurements, drainage, or healing progress. On survey observation, the resident was seen in a wheelchair with a pressure-reducing cushion, but the MDS coordinator stated there was no order for a pressure-reducing mattress or cushion, so the assessment did not reflect one. The resident was also observed receiving lunch without the ordered double protein portion, without the ordered Magic Cup, and without visible protein powder in the tea. Staff interviews indicated confusion about the nutrition orders, that the Magic Cup was not being offered, and that protein powder was being given differently than ordered. The DON acknowledged that wound measurements and documentation needed to be better, that weekly skin assessments were not consistently completed, and that there was confusion among staff about the resident’s wound care and nutrition orders.
Failure to Supervise a Resident With Recurrent Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for one resident reviewed for accidents. The resident had diagnoses including fracture of the right pubis, dementia, abnormalities of gait and mobility, and unsteadiness on feet. The most recent quarterly MDS indicated severe cognitive impairment and dependence on staff for transfers and toileting. The resident’s physician’s orders stated she should not be left unsupervised in her wheelchair while in her room or in the lounge for safety, and the care plan identified her as being at increased risk for falls due to confusion, gait and balance problems, bowel and bladder incontinence, psychoactive drug use, lack of awareness of safety needs, and a history of recurrent falls. Current interventions also stated she should not be left unsupervised in the lounge while in her wheelchair. A nurses note documented that a pressure alarm sounded in the TV lounge and the resident was found lying flat on her back on the floor in front of the TV. RN 3 stated the resident was in the lounge by herself when she fell. The resident’s record lacked a fall assessment after the fall and lacked an interdisciplinary team note after the fall. The DON stated the resident was supposed to be supervised at all times when in the lounge and acknowledged that a fall assessment and IDT note were not present after the fall, although she expected both to be completed after every fall.
Nutrition Orders Not Followed for Resident With Weight Loss
Penalty
Summary
The facility failed to ensure a resident's nutrition plan of care was followed for a resident with weight loss, pressure ulcer, dementia with behaviors, and polyneuropathy. The resident's record showed a regular diet with double portions of protein, protein powder mixed in liquid twice daily, and Magic Cup supplements ordered for weight loss and wound healing. The nutrition care plan also directed staff to provide the ordered diet and supplements, monitor intake, and record every meal, but the care plan had not been revised since 10/17/24 despite later weight loss concerns. The resident's documented weights showed a loss from 148.0 lbs on 11/1/25 to 136.5 lbs on 12/2/25, a 7.8% decrease in 30 days. A weight change note stated the resident was consuming 25-50% of meals on average, had variable appetite, and was receiving Magic Cup once daily, protein powder with meals, and a multivitamin. The note also documented that the NP was notified and new orders were given to increase Magic Cup to each meal and to obtain weekly weights, but the clinical record lacked an order for weekly weights. Staff interviews showed confusion about the weight monitoring order and how often the protein powder should be given. During observation on 1/7/26, the resident's lunch was served without the ordered double portion of protein, a Magic Cup was not offered, and the protein powder was not visible in the tea that was the only liquid served. Interviews with nursing and dietary staff indicated the resident was not consistently receiving the supplements and diet as ordered, and staff were unaware of why the orders were not being followed as written. The DON stated the orders should be followed as written and that the MDS coordinator would revise the care plan, but the care plan had not been updated to reflect the resident-specific nutrition needs.
Resident Dignity and Respect Concerns
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when being spoken to. During an interview, Resident B reported that she had heard a few unnamed staff members speaking harshly to residents from her room and the hallway, including telling residents to "shut your mouth," forcing residents to go to bed when they did not want to, being hateful, cursing, and being short with residents. Resident B stated this behavior had been occurring for several months and that grievances had been filed and the issue had been brought up in resident council meetings, but the behavior continued. She said the conduct angered her because she was concerned about the other residents involved. The Activities Assistant confirmed that residents had raised concerns in resident council meetings that staff were cursing, griping, and being snippy with residents, and she stated she had completed at least two grievances related to staff behavior. The Administrator acknowledged awareness of the complaints and grievances and stated education had been provided regarding resident rights, professionalism, phone use, and tone. Resident council minutes documented repeated concerns about staff being mean, using the F word, being on phones, being abrasive, being a smart---, and being gripey. Grievance records also documented complaints that staff were short, rude, abrasive, and unprofessional, including a CNA being in a rush and getting residents up before they wanted to.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
The facility failed to ensure the safe, secure, and orderly storage of medications in both a medication cart and a medication storage room. In one instance, a medication cart contained Alka-Seltzer, melatonin, and Dulcolax in an original box with a resident's name handwritten on it, but without any labeling indicating the ordered dosage, route, frequency of administration, or prescriber name. The medications had been brought in by the resident's family without a physician's order, and there was no documentation in the resident's medical record regarding the receipt of these medications or physician notification. The resident's physician orders did not include these medications, and nursing progress notes lacked any mention of the family's action or subsequent staff response. Additionally, the medication storage refrigerator in a medication storage room was found to contain both resident beverages and medications, with a temperature log that was not consistently completed as required by facility policy. Several shifts had missing temperature documentation, despite the policy stating that temperature checks must be completed each shift. Staff interviews confirmed that the required procedures for labeling, physician orders, and temperature monitoring were not followed, and facility policies were provided that outlined these requirements.
Failure to Perform Hand Hygiene Between Glove Changes and After Glove Removal
Penalty
Summary
During an observation of care, two CNAs assisted a resident with toileting and perineal care. After providing perineal care, one CNA removed (doffed) used gloves and immediately donned new gloves without performing hand hygiene in between glove changes. Both CNAs then assisted the resident with dressing and transferring to a wheelchair. Subsequently, the CNA removed gloves and, without performing hand hygiene, opened the resident's bedside table drawer and handed the resident a hair comb. The CNA verbally indicated to the resident that she needed to wash her hands, but did not perform hand hygiene herself at the required times. The facility's infection preventionist confirmed during an interview that staff are expected to change gloves when moving from dirty to clean tasks and to perform hand hygiene between glove uses and immediately after removing gloves. Review of the facility's hand hygiene policy also indicated that hand hygiene should be performed after removing gloves and as the final step after removing personal protective equipment. These lapses in infection control practices were directly observed and confirmed through staff interviews and policy review.
Failure to Prevent and Treat Pressure Wounds
Penalty
Summary
The facility failed to provide adequate care to prevent and treat pressure wounds for two residents, Resident D and Resident F. For Resident D, initial observations of deteriorating skin areas were not documented or communicated, and initial wound care was not documented following the development of pressure wounds. Despite being at risk for pressure wounds as indicated by a Braden Scale assessment, no care plan was in place to prevent the development of pressure wounds. Additionally, ordered treatments for existing wounds were not consistently completed, with several instances where treatments were missed because the resident was asleep, which was deemed an inappropriate reason by the staff. Resident D had multiple wounds, including on the feet and coccyx, with diagnoses such as hemiplegia, type II diabetes, and obesity. The resident's care plan included interventions for deep tissue injuries and skin integrity impairments, but there was a delay in initiating a care plan for a wound first observed on the gluteal fold. The treatment administration record showed missed treatments, and weekly wound assessments indicated worsening conditions of the wounds over time. Interviews with staff revealed a lack of awareness and communication regarding the resident's wounds, contributing to the deficiency. Resident F, with diagnoses including neurocognitive disorder and protein-calorie malnutrition, was also at risk for pressure wounds. A skin check revealed a pink area on the coccyx, which later worsened to a Stage II pressure wound. There was no documentation of a wound treatment order or administration prior to a specific date, and the wound assessments showed a progression in the severity of the wound. Staff interviews highlighted a lack of communication and documentation regarding changes in the resident's skin condition, which contributed to the deficiency in care.
Inadequate Infection Preventionist Staffing
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as required for the infection prevention and control program. The Director of Nursing (DON) was appointed as the facility's IP while also serving as the full-time DON. During interviews, the DON admitted that the time spent on IP duties varied weekly and was less than desired. Additionally, there was no documentation available to verify the hours worked specifically for IP duties. The job description provided for the IP role was current but undated, indicating the responsibilities for controlling the spread of infections and outbreaks.
Failure to Document Contraindication for GDR in Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, who was prescribed psychotropic medication, had a documented clinical contraindication for not undergoing a gradual dose reduction (GDR). The resident, diagnosed with anxiety and depression, was taking Alprazolam 0.5mg twice daily since April 2023. A nurse's note from January 2024 indicated a recommendation for a GDR to decrease the dosage to 0.25mg, which was denied on the grounds that it would not be in the resident's best interest. However, no further documentation of contraindication was found in the resident's clinical record. The facility's Medication Monitoring policy requires a GDR to be attempted within the first year after admission or initiation of the medication, and annually thereafter, unless clinically contraindicated with documented rationale from a physician.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, distribution, and service, as observed in the kitchen. Dietary staff members were seen with hair not fully covered by hairnets, and food temperature logs were incomplete for several meals over a week-long period. Additionally, measuring devices were improperly stored inside containers of food items such as oats, sugar, and ice. Staff were observed handling food with bare hands, including touching bread and using a measuring spoon from a thickener container without gloves. Furthermore, the facility did not ensure that food items on resident trays were covered during transport. Certified Nurse Aides and Dietary Aides were observed carrying trays with uncovered drinks and desserts through hallways to resident rooms. The facility's policy, as indicated by the Administrator, requires that food be covered in the halls, hair be fully contained in hairnets, and gloves be used when handling food. However, these practices were not consistently followed, leading to deficiencies in food safety and hygiene.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections during incontinence care for three residents. Observations revealed that Certified Nurse Aides (CNAs) did not perform hand hygiene between glove changes and did not change gloves after touching multiple items before starting incontinence care. For Resident 13, CNAs did not change gloves after adjusting the bed and handling the resident's brief, and one CNA did not sanitize her hands before putting on new gloves. Similarly, during the care of Resident 27, CNAs failed to perform hand hygiene between glove changes and did not offer the resident an opportunity to wash her hands after using the bathroom. In the case of Resident 15, CNAs did not perform hand hygiene before putting on gloves and failed to sanitize hands between glove changes after assisting with a bowel movement. The facility's Infection Preventionist indicated that staff should sanitize hands before putting on gloves and between dirty and clean tasks, as per the facility's Handwashing/Hand Hygiene Policy. This policy emphasizes hand hygiene as the primary means to prevent infection spread, requiring handwashing with soap and water when hands are visibly soiled and the use of alcohol-based hand rubs before and after direct resident contact and after removing gloves.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and home-like environment across multiple areas, including five halls and a dining room. Observations revealed numerous issues such as unlabeled personal items in shared bathrooms, dust-caked vent fans, soiled toilets, peeling non-skid strips, missing paint, and uncovered incontinence pads in shower rooms. Specific rooms, such as Room B6 and its shared bathroom, had peeling non-skid strips, soiled caulking, and dusty vent fans. Similar conditions were noted in other rooms, with additional issues like overflowing trash cans and unlabeled personal hygiene items. The dining room floor was found to be uneven, cracked, and peeling, with discoloration observed. In the shower rooms, there were soiled grout, worn non-skid strips, and uncovered hygiene supplies. The facility also had structural issues, such as cracked ceiling tiles and light casings, and sand-like debris was noted on the floor in certain areas. Vent fans in various locations, including above the nurse's station and in hallways, were consistently observed to be caked with dust. Interviews with staff, including an LPN and the Housekeeping Supervisor, highlighted a lack of adherence to cleaning protocols and labeling of personal items. The Housekeeping Supervisor indicated that rooms should be cleaned daily according to a checklist, but there was no formal policy in place. The Infection Preventionist noted that incontinence pads should be stored covered, and personal items should be labeled, especially in shared spaces. Despite these expectations, the facility's environment did not meet the standards outlined in their Quality of Life-Homelike Environment policy.
Failure to Revise Care Plans and Obtain Orders for Alarms
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident 29, who was admitted after a fall resulting in a fracture and had diagnoses including dementia and depression, had discontinued orders for bed and chair alarms. However, the care plan did not reflect this change, and alarms were still in use without a current physician's order. The oversight occurred after the resident's hospitalization, where all orders were supposed to be re-entered upon readmission, but the alarms were omitted in error. Observations confirmed the continued use of alarms, and staff interviews revealed that orders should have been placed shortly after initiating alarms. Resident 1 was observed with bed and chair alarms in use, but the clinical record lacked orders for these alarms, and the care plan did not include them as interventions. Despite the resident's cognitive impairment and need for assistance, the alarms were not documented as part of the care plan. Similarly, Resident 2's care plan included outdated interventions for diuretic and antibiotic therapy, which were no longer applicable as the resident lacked a current UTI diagnosis. The MDS Coordinator acknowledged the need for care plan updates when orders are discontinued, but this had not been done. The facility's policies on care plans and alarms were not adhered to, contributing to these deficiencies.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. For Resident 133, the facility did not adhere to the physician's order for oxygen administration. Observations revealed that the resident was receiving oxygen at different levels than prescribed, and staff were unsure of the correct settings. The resident's clinical records indicated a diagnosis of COPD and hypertension, with a physician's order for oxygen at 1 LPM, which was not consistently followed. Resident 6 was observed with improper storage of respiratory equipment, including oxygen tubing and a nebulizer mouthpiece. The tubing was found uncovered on the floor, and the nebulizer mouthpiece was left uncovered on the nightstand, contrary to infection control protocols. The resident's clinical records showed a diagnosis of dementia with behavioral disturbance and COPD, with orders for continuous oxygen therapy. Staff interviews confirmed that the equipment should have been stored in a provided bag when not in use. For Resident 28, the facility failed to obtain a physician's order for oxygen, despite the resident using it continuously. Observations showed the resident using oxygen at 2 LPM, but the clinical records lacked a specific order for oxygen administration. The resident's diagnoses included COPD with acute exacerbation, and care plans indicated the use of oxygen therapy. Staff interviews revealed that there was an expectation for an order, but it was not present in the records. The facility's policies on oxygen administration and infection control were not followed, contributing to the deficiencies observed.
Medication Administration Deficiency Due to Pharmacy Delays
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident, as evidenced by the improper administration of medications. During an observation, a registered nurse (RN) was unable to locate the prescribed Miralax for one resident and subsequently administered the medication from another resident's supply. Similarly, the RN could not find the Colace for another resident and used the medication from a different resident's card. These actions were contrary to the facility's medication administration policy, which explicitly states that medications supplied for one resident should never be administered to another. The Director of Nursing (DON) acknowledged ongoing issues with the pharmacy, including delays in medication delivery and the absence of a pharmacist after 5 P.M. The pharmacy's failure to deliver medications on time, particularly those on auto-refill, forced nursing staff into a position where they had to choose between not administering necessary medications or borrowing from other residents. The DON confirmed that the pharmacy was expected to deliver medications within four hours of a request, but this was not consistently happening, contributing to the deficiency.
Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a secured environment, resulting in a resident with dementia exiting the facility unsupervised. On the specified date, the resident was last seen by staff at approximately 2:20 P.M. and was not noticed missing until 3:15 P.M. A search was initiated, and the resident was found by the Activity Director approximately 200 yards off the facility property along a gravel road. The resident was returned to the facility without injury. The deficiency was linked to a failure in the facility's alarm system. The back door near the kitchen, through which the resident exited, was not alarming when opened. It was discovered that the door alarm had been silenced for an unknown reason and had not been reset. The facility's electronic security control panel, which should have indicated the door's status, was not effectively monitored, allowing the resident to leave unnoticed. The resident involved had a history of elopement and was at risk for such behavior, as indicated by previous incidents and assessments. Despite wearing a WanderGuard bracelet, the back door was not equipped with a WanderGuard system, allowing the resident to exit. The resident's care plan included interventions for impaired cognitive function and elopement risk, but these measures were insufficient to prevent the incident.
Violation of Resident Privacy Due to Unauthorized Video Recording
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident, identified as Resident B, by allowing a video recording to be made in the resident's restroom where the resident was identifiable. The incident came to light when an anonymous community member reported a video on a social media site to the Business Office Manager. The video showed a staff member, CNA 4, in the restroom with Resident B visible in the background sitting on the commode with her stomach exposed. The video was posted by Unlicensed Staff (US) 3, who, along with CNA 4, was later suspended and terminated from employment. CNA 4 claimed to be unaware of the video being taken, although she was seen posing in the video. Resident B, who has diagnoses including dementia, overactive bladder, and anxiety, was assessed to have moderate cognitive impairment. The facility's investigation revealed that the incident occurred a few months prior when CNA 4 and US 3 were assisting Resident B to the restroom. The facility's policy prohibits the use of camera or recording devices on the premises to comply with HIPAA regulations, and staff are strictly prohibited from recording or photographing residents. The facility's policy on resident rights also emphasizes the right to personal privacy, including during personal care.
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What surveyors actually found near you
We read the 133 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Loogootee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sycamore Care Strategies | 10.7 mi | ★★★★★ | 2 | 1 |
| Bertha D Garten Ketcham Memorial Center | 12.5 mi | ★★★★★ | 4 | 0 |
| Eastgate Manor Nursing And Rehabilitation | 12.8 mi | ★★★★★ | 0 | 0 |
| Hillside Manor Nursing Home | 13.6 mi | ★★★★★ | 31 | 1 |
| Villages At Oak Ridge, The | 14 mi | ★★★★★ | 1 | 0 |
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